Provider Demographics
NPI:1164699401
Name:MOSS, AUDREY ROCK (LAC, LMT)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:ROCK
Last Name:MOSS
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 SE 82ND AVE
Mailing Address - Street 2:STE 1000 - 145
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2924
Mailing Address - Country:US
Mailing Address - Phone:503-481-4615
Mailing Address - Fax:503-233-8415
Practice Address - Street 1:5667 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3747
Practice Address - Country:US
Practice Address - Phone:503-481-4615
Practice Address - Fax:503-233-8415
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01141171100000X
OR8563225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist